Många läkemedelsbiverkningar manifesterar sig i munhålan.

Biverkningar i munhålan är sällan livshotande, men kan ändå ha stor inverkan på patienters välbefinnande och livskvalitet.

Både läkare och tandläkare behöver kunna identifiera och reagera på biverkningar i munhålan och ibland samverka kring åtgärder och behandling av dessa.

Både läkare och tandläkare har en skyldighet att rapportera misstänkta läkemedelsbiverkningar till Läkemedelsverket, oavsett var förskrivningen skett.

Adverse drug reactions commonly occur in the oral cavity, and although these reactions are seldom life threatening, they may severely affect quality of life, as well as the nutritional status of the patient. Hyposalivation is often caused by antidepressants, antihistamines, and diuretics, and the risk increases with polypharmacy. A dry mouth may in turn lead to oral candidosis, which may also be caused by treatment with antibiotics, immunosuppressants or corticosteroids. Other possible adverse drug reactions that may be seen in the oral cavity include gingival hyperplasia, ulcerations, allergic mucosal reactions, changes in sensibility or taste, as well as discoloration of saliva and/or the oral mucosa. Drug-induced osteonecrosis of the jaw from bisphosphonates is also mentioned in this context. The risk of many adverse drug reactions in the mouth can be decreased by good oral hygiene, in combination with regular revisions of the patient's drug treatment. However, there is a risk that physicians do not examine the oral cavity, while dentists may not have complete information about the patient's drug treatment. A close collaboration between medical and dental health care is the key to reducing adverse drug reactions in the mouth.

Rationell läkemedelsanvändning är ett brett begrepp. Det innebär att patienten ordineras läkemedel som är väl lämpade utifrån kliniska behov och att nyttan förväntas överväga riskerna med behandlingen hos individen. Vidare krävs det att patienten är informerad och motiverad att genomföra behandlingen och att det finns möjligheter till att följa upp effekt och säkerhet. Risk-nyttabalansen behöver omvärderas regelbundet, eftersom förutsättningarna (till exempel njurfunktion och samsjuklighet) kan ändras över tid. Slutligen krävs det att behandlingen avslutas på ett skonsamt sätt när indikationen inte längre kvarstår, eller när nyttan inte längre med säkerhet överväger risken. Ur ett samhällsperspektiv bör dessutom kostnaden för behandlingen vara rimlig i relation till nyttan och till andra behandlingsalternativ. Miljöaspekter av läkemedelsanvändning behöver också vägas in.

Utmaningen för förskrivaren är dels att värdera nytta och risk med läkemedel utifrån den information som finns tillgänglig, dels att förstå hur data på gruppnivå ska tillämpas på den enskilda patienten. Det här kapitlet behandlar grundläggande principer för att individanpassa läkemedelsval och dosering, med utgångspunkt i läkemedlens verkan och omsättning, samt verktyg för läkemedelsuppföljning och utsättning av läkemedel.

Purpose: Sharing and developing digital educational resources and open educational resources has been proposed as a way to harmonize and improve clinical pharmacology and therapeutics (CPT) education in European medical schools. Previous research, however, has shown that there are barriers to the adoption and implementation of open educational resources. The aim of this study was to determine perceived opportunities and barriers to the use and creation of open educational resources among European CPT teachers and possible solutions for these barriers.

Methods: CPT teachers of British and EU medical schools completed an online survey. Opportunities and challenges were identified by thematic analyses and subsequently discussed in an international consensus meeting.

Results: Data from 99 CPT teachers from 95 medical schools were analysed. Thirty teachers (30.3%) shared or collaboratively produced digital educational resources. All teachers foresaw opportunities in the more active use of open educational resources, including improving the quality of their teaching. The challenges reported were language barriers, local differences, lack of time, technological issues, difficulties with quality management, and copyright restrictions. Practical solutions for these challenges were discussed and include a peer review system, clear indexing, and use of copyright licenses that permit adaptation of resources.

Conclusion: Key challenges to making greater use of CPT open educational resources are a limited applicability of such resources due to language and local differences and quality concerns. These challenges may be resolved by relatively simple measures, such as allowing adaptation and translation of resources and a peer review system.

The prescription of medicines is one of the most common acts performed by physicians. Yet, several studies have shown that junior doctors are not well prepared for the task. The teaching of basic and clinical pharmacology varies greatly between universities, both within Sweden and in Europe. National prescribing exams have been introduced in the UK, the Netherlands and Belgium, and there is an on-going project to develop a European exam, focusing on a list of essential medicines and patient safety. With the new six year curriculum for medical education in Sweden, the license to prescribe could be linked to a national prescribing exam, to ensure good knowledge of both therapeutics and Swedish drug regulation.

Flera studier pekar på att nyfärdiga läkare, både i Sverige och i övriga Europa, har bristande läkemedelskunskaper.

Initiativ pågår för att ta fram en europeisk förskrivarexamen.

En nationell läkemedelsexamen som villkor för fri förskrivningsrätt skulle stödja läkemedelslärandet hos läkare utbildade både i Sverige och i andra länder.

Aim: Improvement and harmonization of European clinical pharmacology and therapeutics (CPT) education is urgently required. Because digital educational resources can be easily shared, adapted to local situations and re-used widely across a variety of educational systems, they may be ideally suited for this purpose.

Methods: With a cross-sectional survey among principal CPT teachers in 279 out of 304 European medical schools, an overview and classification of digital resources was compiled.

Results: Teachers from 95 (34%) medical schools in 26 of 28 EU countries responded, 66 (70%) of whom used digital educational resources in their CPT curriculum. A total of 89 of such resources were described in detail, including e-learning (24%), simulators to teach pharmacokinetics and/or pharmacodynamics (10%), virtual patients (8%), and serious games (5%). Together, these resources covered 235 knowledge-based learning objectives, 88 skills, and 13 attitudes. Only one third (27) of the resources were in-part or totally free and only two were licensed open educational resources (free to use, distribute and adapt). A narrative overview of the largest, free and most novel resources is given.

Conclusion: Digital educational resources, ranging from e-learning to virtual patients and games, are widely used for CPT education in EU medical schools. Learning objectives are based largely on knowledge rather than skills or attitudes. This may be improved by including more real-life clinical case scenarios. Moreover, the majority of resources are neither free nor open. Therefore, with a view to harmonizing international CPT education, more needs to be learned about why CPT teachers are not currently sharing their educational materials.

A prerequisite for rational use of medicines is adequate prescribing skills; drug treatment is a complex task requiring diagnostic competence combined with pharmacologic knowledge and patient communication skills. Acquiring professional confidence in the art of prescribing is essential during medical training. The results of this questionnaire study, conducted in four medical schools in Sweden after the course in internal medicine (252 respondents; response rate: 74%; median age: 24 years, 61% female), show that 45% and 62% were confident in performing medication reviews and writing medication summary reports, respectively, i.e. the basics of prescribing. The confidence increased by the number of reviews and reports performed, i.e. the extent of practice (correlation coefficients: 0.41 and 0.38, respectively, both pamp;lt;0.0001), as did the extent of the students reflection on important aspects of drug treatment such as adherence, adverse reactions, renal function, dosing, and drug interactions. In multivariate regression analyses, major predictors for confidence in performing medication reviews were extent of practice and extent of clinical supervision. The results suggest that these factors are keys to acquiring professional confidence in the art of prescribing.

Att behandla med läkemedel är en kärnuppgift för läkare; grundutbildningen behöver ge studenterna förutsättningar att klara detta.

Enkätresultat från fyra lärosäten visade att 45 procent av studenterna efter sin invärtesmedicinska placering kände sig trygga med att göra läkemedelsgenomgångar och 62 procent med att skriva läkemedelsberättelser.

Studenter som gör många läkemedelsgenomgångar/läkemedelsberättelser känner större trygghet och reflekterar mer över patientens behandling.

Klinisk handledning gör skillnad.

När kursplaner revideras vid införandet av en sexårig läkarutbildning, med förskrivningsrätt direkt efter examen, behöver klinisk träning i läkemedelsarbete inklusive handledning tydliggöras.

Background: The aim of this study was to compare use of references in responses from Scandinavian drug information centres (DICs). Methods: Six different fictitious drug-related queries were sent to each of seven Scandinavian DICs. The six queries concerned adverse effects, pharmacokinetics, pregnancy, complementary medicine, polypharmacy, and breast feeding. References in the responses were categorised into five types of drug information sources: primary (original studies), secondary (reviews), tertiary (drug monographs, handbooks, etc.), DIC database, or personal communication. Results: Two hundred and forty-four references were used in the 42 responses. The mean number of references varied from 3.0 to 10.6 for the six queries. The largest difference between centres with regard to number of references used (range 1?17) was found for the query on complementary medicine. In total, 124 references (50.8%) were tertiary, and only 10 of the 42 responses (23.8%) did not have any tertiary references included. Complementary medicine, breast feeding, and pregnancy were query types associated with relatively frequent use of primary references. Use of DIC database was not uncommon, but personal communications were seldom used. Conclusions: Scandinavian DICs differ substantially in number and type of references to identical drug-related queries. Tertiary sources are mainly preferred irrespective of type of query.